Across the athenahealth network and beyond, healthcare organizations are designing and implementing simple interventions with outsized impact on outcomes, satisfaction, and success. Here's another.

The problem

At Hayward Wellness, an ambulatory care clinic in the Alameda Health System, physicians could screen patients for risk factors related to social determinants of health, but were unable to address obstacles to better health outcomes in a systematic way.

Without the means to solve problems in their patients' lives, Hayward's providers hesitated to even bring challenges up with patients during appointments.

“The gap between the provider on the ground screening for these important issues and the actual delivery system for intervention is so big that providers feel overwhelmed," says Steven Chen, M.D., medical director at Hayward — overwhelmed and unable to make any difference.

The solution

In 2017, Hayward Wellness decided to tackle that gap. With seed funding from Kaiser Permanente's Community Benefit program provided over three years, Hayward Wellness developed and enhanced an innovative intervention. It began by screening for food insecurity, a factor likely to identify patients with a host of complex needs, and stratified patients into low-, medium-, or high-risk groups.

Next, the clinic created a network of in-house and community resources and grouped those resources into three "pharmacies" to address foundational drivers of health:

• The Food Farmacy: In partnership with Dig Deep Farms, a local network of food-integrated businesses and nonprofits, Hayward established an in-clinic farmer's market providing fresh produce.
• The Social Needs Pharmacy: Working with Alameda Health System's Health Advocates, Hayward built a bilingual navigation help desk to field patient phone calls and connect them with resources for housing, health insurance, public benefits, immigration support, and legal advice.
• The Behavioral Pharmacy: Combining Open Source Wellness behavioral resources with Hayward's group medical visit model, Hayward providers are able to connect patients to behavioral health resources from within their workflow and integrate those referrals into patients' records. As Chen says, they "created a delivery system for patients to easily accomplish movement, mindfulness, healthy eating, and connectivity."

With these resources in place, Hayward's low-risk patients are now informed about CalFresh, the state's SNAP food-assistance program. Medium- and high-risk patients are given prescriptions to be "filled" at one or more of the pharmacies.

Now Hayward's providers have a toolkit to effectively address the upstream causes of poor health from within the clinical workflow.

The outcome

Today, Hayward Wellness has screened 95 percent of its patients, identifying 17-19 percent as food insecure, well above the national average of 12 percent, and its providers have written over 1,400 Food Farmacy and 550 Social Needs Pharmacy prescriptions.

Concurrently, Hayward's clinical pharmacists saw a 2 percent decrease in HbA1c levels in over 100 patients. The Behavioral Pharmacy reports declines in rates of anxiety, depression and loneliness as well.

And a recent study suggests that Hayward is on the right track in addressing social determinants of health, which can reduce overall healthcare costs by 10 percent or more. “We are trying to work upstream in multiple ways," says Chen. "There is a way to do this type of medicine."

Lia Novotny is a frequent contributor to athenaInsight.